Author Topic: 2016 Humana Denying EKG 93000 during Well Exam - Code 07S 07R  (Read 1763 times)

barcafan1990

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Has anybody received denials from Humana for EKG 93000 service performed during a CPE well exam?
I've had a few and they are being denied for similar reasons which I am almost certain is a Humana glitch.

The Humana reason codes are
07S: service incompatible with members age and pos submitted
07R: service incompatible with members aga and dx submitted

Also on the eob are ANSI (HIPAA) reason codes that seem to be duplicate affirmation of Humana's reason codes:
5: cpt code inconsistent with POS
6: cpt code inconsistent with pt age

I say this is a Humana glitch because, being a CPE visit with EKG, identical claims have been billed and paid for the exact patient in previous years. Therefore, why would the pos (in our case its 11-office which hasn't changed) and/or pt age be a problem)?

 I am having to call and get a hold of a Humana CSR to get them to reprocess the claim. Of course they make it difficult by requesting that I provide them with a previous DOS that was billed and paid for in a similar manner PLUS fax them a copy of the current DOS. They end up paying for the EKG without any changes to the claim so I am confused as to why Humana is denying it in the first place and making me jump through their hoops to get it reprocessed and paid.

Any suggestions? I can't figure out any other reason the claim is being denied. (Its coded correctly with mod 25 on the 99396)
Thanks.
Josue M

Michele

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Re: 2016 Humana Denying EKG 93000 during Well Exam - Code 07S 07R
« Reply #1 on: April 13, 2016, 09:08:52 AM »
I haven't seen this but we don't see a lot of Humana.  It sounds like you are doing everything correctly.  On the next one I would ask for an explanation as to why it was denied and if there is something that you can do to avoid this in the future.  Making them spell it out may give you some answers.

Good luck!
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barcafan1990

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Re: 2016 Humana Denying EKG 93000 during Well Exam - Code 07S 07R
« Reply #2 on: April 13, 2016, 12:17:13 PM »
Thank you Michele. I will see if I can get some more details. Usually the rep that I get a hold of will not give me a straight answer, aside from reading me back verbatim the reason code description,  but rather simply offer to have the claim sent back for review. I suppose I could call back after I receive payment for the claim.
Josue M